Training illiterate frontline health workers:
strategies used and lessons learned in rural South Sudan
Juli Hedrick, MPH; Alfonso Rosales, MD, MPH-TM; Dennis Cherian, BHMS, MPA, MA; Kuol Kuol Amet
Abstract
Purpose: In rural South Sudan, where only 26% of those
over age 15 have ever attended school, older women
serving as frontline volunteer health workers –Home
Health Promoters (HHPs) –often have had minimal access
to formal education. In preparation for an operations
research embedded in a centrally-funded USAID Child
Survival and Health Grants Program project in Warrap State
(2010-2014), World Vision staff trained 15 illiterate HHPs
from a rural community, ranging in age from 32-50, in March
2013 to deliver integrated community case management
plus essential newborn care, including newborn
resuscitation. Data used: Quantitative (pre/post tests and
skill evaluation) and qualitative (observation and lead
trainer’s notes) information was used to evaluate the
training. Methods: Working through translation and using a
variety of approaches including sharing of experiences,
hands-on activities, songs, videos, pictorial recording forms,
and cue cards, trainers observed skill transfer during final
testing. Results: The training achieved 100% attendance. A
12 question verbal pre-test/ post-test showed increases in
knowledge; particularly of identification of danger signs and
use of breath counting to determine fast breathing. At
week’s end, 12 of 15 passed competency testing for
newborn resuscitation. Nine of 15 training attendees were
found to be sufficiently competent in all skill areas, including
use of recording forms, to receive project accreditation at
the conclusion of training, with 13 of 15 accredited within
six weeks of supervision. Recommendations: Illiterate
volunteers can demonstrate community case management
and essential newborn care skills learned through intensive
hands-on training utilizing a variety of approaches, followed
by supportive supervision.
Objective
The primary objective of the five day training was to
transfer skills to 15 HHPs in the correct use of the
integrated community case management (iCCM) plus
essential newborn care approach in their communities.
iCCM+ is adapted from health interventions from
Integrated Management of Childhood Illness,1 Helping
Babies Breathe, 2 and Home-Based Life Saving Skills. 3
The objective would be fully met if a participant
demonstrated competence using the approach during skills
testing. Written (demonstrated correct use of the flipchart
and corresponding recording and referral forms) and
demonstrated (newborn resuscitation, counting of
respirations, and administration of medications) skills were
included in skills testing.
1World
Health Organization, 2American Academy of Pediatrics
3American College of Nurse-Midwives
Strategies
Literature Review and Discussion
Prior to the training session, USbased project staff met with
Government of South Sudan
Ministry of Health representatives
at the national, state, and county
levels to refine the approach and
protocols, and to ensure alignment
with all government strategies.
Translation of materials and training
sessions into Dinka, the
predominant local language, was
facilitated by local staff.
Strategies used to teach the
iCCM+ approach included group
sharing, picture cue cards, flipcharts
and recording/referral forms, WHO
and Global Health Media Project
Videos, field practicums in nearby
villages, skills testing, and supportive
supervision.
Classroom Learning
Field Exercises
Practice with charts and forms
Skills Testing
Peer Support
Supportive Supervision
Lessons Learned
1. Personalize and contextualize: Each unit began with a time for sharing of experiences on diarrhea, pneumonia, malaria,
and newborn care. These grew lengthier daily, surpassing the time allotted, but allowed participants to fully engage with the
training sessions on a personal level. Followed by World Health Organization videos on the same topics, participants
broadened their own perspectives and were reassured that such experiences are universal amongst frontline health
workers. Through this exercise, participants became more engaged with the training program.
2. Use organizational aids: Most participants had never held a pencil, turned the pages of a flipchart, or used a paper clip.
The approach required participants to learn pictorial flash cards, reference the flipchart, confer with a parent, check a child,
and mark on a paper. This was exacerbated by a hot, dusty, environment that necessitated open windows, and wind gusts
would scatter loose papers. In the future, clipboards or small boxes, magnets, or other organizational aids should be used.
3. Put participants in their element: For participants unused to classroom learning, field exercise sessions in nearby
communities accomplished not only the intended goal of skills practice, but also provided a needed respite from the
unfamiliar and often didactic classroom environment. Participants returned to classroom-based activities refreshed and
empowered from positive community feedback.
4. Embrace local culture: The trainers used the local culture’s proclivity for singing to assign ‘homework’ of composing a
song about childhood illness danger signs. This voluntarily became a nightly activity for the participants, who solidified much
of their learning through song.
5. Be willing to redefine success: The original training objective was to determine which HHPs demonstrated competency
and therefore would participate in the supportive supervision process. However, it quickly became apparent that many
would need additional time. All HHPs were therefore followed by the supervisor, and within six weeks all but two reached
the intended level of competency.
6. Follow up with supportive supervision: Twelve weeks of weekly one-on-one supportive supervision by a field
supervisor, himself supervised at the central level, provided steady encouragement, training, and correction.
Successful CHW programs, “improve access to and
coverage of communities with basic health services,”
(Lehmann and Sanders, 2007), filling an integral role in the
health sector. Formal education and literacy level have little
bearing on the selection of CHWs. Brown, et al. (2006)
found that 90% of traditional birth attendants in Peru were
illiterate, and “in the case of health promoters, 1% were
illiterate, 48% had incomplete primary school education and
only 8% of these agents had completed high school.”
Hermann, et al. (2009) emphasized that “belonging to (the)
community is crucial. Prior level of education is less
important, although literacy and numeracy facilitate
participation in training and follow-up activities.” Juxtaposed
with this information is the finding that “most healthcare
materials are written at an 11th grade reading level” and “the
most commonly used methods for training CHWs were
pedagogic,” (O’brien et al, 2009) highlighting the importance
of utilizing a variety of training methods and tools.
While CHW programs are varied, the literature confirms
that in practice there are common themes defining
successful programs. Communities must have direct
connection to the selection of CHWs. Training must be
appropriate to the level of education. Training sessions
followed by regularly scheduled refresher training is
supported by the literature as appropriate and effective.
Successful CHW programs fill an integral role in the health
sector.
References and Resources
Brown A, Malca R, Zumaran A, Miranda JJ (2006). On the front line of
primary health care: the profile of community health workers in rural
Quechua communities in Peru. Hum Resour Health 4(1):11.
Global Health Media Project newborn and breastfeeding videos:
globalhealthmedia.org/videos © 2014
Helping Babies Breathe © American Academy of Pediatrics 2010
Hermann, K.,Van Damme, W., Pariyo, G., Schouten, E., Assefa, Y., Cirera,
A., and Massavon, W. (2009) Community health workers for ART in subSaharan Africa: learning form experience – capitalizing on new
opportunities. Human Resource Health, 7:31.
Home Based Life Saving Skills, America College of Nurse-Midwives
2010
Lehmann, U. and Sanders, D. (2007) Community health workers: what
do we know about them? A World Health Organization report.
O'Brien, M., Squires, A., Bixby, R, & Larson, S.C. (2009). Role
development of community health workers: An examination of selection
and training processes in the intervention literature. American Journal of
Preventive Medicine, 37(6): S262-269.
World Health Organization IMCI training videos, © World Health
Organization, 2015
Acknowledgements/ Contact
The authors wish to acknowledge the funding support of the United
States Agency for International Development’s Child Survival and Health
Grants Program. For more information please contact Juli Hedrick at
[email protected] World Vision, Inc. 300 I St. NE, Washington,
D.C. 20002 worldvision.org